Clinical Appeal Nurse Lead - IL/WI Lic Required

American Addiction Centers • Milwaukee, WI

3d • $40 - $60 • Remote

About The Position

Government Audit Appeals (Remote SE/MW regions) Enterprise with IL and WI/NC/GA state license Where You Will Work: Remote Government Appeals in MW/SE regions We’re Looking For: • BSN required Registered Nurse license issued by the state in which the teammate practices (add Compact State WI/NC and IL Extensive knowledge of Government Audits to lead a clinical RN team to produce expert level appeals for denials associated with LCD/NCD and CMS regulatory components. Prior appeal writing for CMS government denials required. Extensive background in hospital and professional claim billing as well as DRG/CPT coding knowledge required. Strong leader and interpersonal skills required to include education/mentoring for ongoing government audits to develop and enhance team skills to effectively defend denials and ensure financial recovery of reimbursements. What You’ll Do: Responsible for training, evaluating and staffing coverage for Revenue Recovery. Performs quality review process audits and staff feedback. Ensures acceptable productivity levels and assigned tasks/appeals are completed Identify process inefficiencies and opportunities for daily workflow improvement and participate in developing new processes with Revenue Recovery Manager. Keeps abreast of current standards, regulations, and issues related to denials and Revenue Recovery including but not limited to, Government and Insurance Payer reimbursement regulations, clinical practices, utilization management, process improvement and health care industry trends via literature, educational offerings, federal register, etc. Maintains an effective working relationship with both internal and external customers. Perform clinical denial review and appeals as needed based on coverage needed. Ensure personal and staff productivity goals are met or exceeded. Monitors and manages daily reports to ensure timely appeals per payer requirements. Solid knowledge of CMS and other regulatory requirements. Solid understanding of process improvement. Demonstrated flexibility, teamwork, and system thinking. Proven understanding and analyzing claims and medical records. Our Commitment to You: Advocate Health offers a comprehensive suite of Total Rewards: benefits and well-being programs, competitive compensation, generous retirement offerings, programs that invest in your career development and so much more – so you can live fully at and away from work, including: Compensation Base compensation listed within the listed pay range based on factors such as qualifications, skills, relevant experience, and/or training Premium pay such as shift, on call, and more based on a teammate's job Incentive pay for select positions Opportunity for annual increases based on performance Benefits and more Paid Time Off programs Health and welfare benefits such as medical, dental, vision, life, and Short- and Long-Term Disability Flexible Spending Accounts for eligible health care and dependent care expenses Family benefits such as adoption assistance and paid parental leave Defined contribution retirement plans with employer match and other financial wellness programs Educational Assistance Program About Advocate Health Advocate Health is the third-largest nonprofit, integrated health system in the United States, created from the combination of Advocate Aurora Health and Atrium Health. Providing care under the names Advocate Health Care in Illinois; Atrium Health in the Carolinas, Georgia and Alabama; and Aurora Health Care in Wisconsin, Advocate Health is a national leader in clinical innovation, health outcomes, consumer experience and value-based care. Headquartered in Charlotte, North Carolina, Advocate Health services nearly 6 million patients and is engaged in hundreds of clinical trials and research studies, with Wake Forest University School of Medicine serving as the academic core of the enterprise. It is nationally recognized for its expertise in cardiology, neurosciences, oncology, pediatrics and rehabilitation, as well as organ transplants, burn treatments and specialized musculoskeletal programs. Advocate Health employs 155,000 teammates across 69 hospitals and over 1,000 care locations, and offers one of the nation’s largest graduate medical education programs with over 2,000 residents and fellows across more than 200 programs. Committed to providing equitable care for all, Advocate Health provides more than $6 billion in annual community benefits. This is Transformation One shared purpose brought us together. Now, as one of the 10 largest not-for-profit, integrated health systems in the United States, our combined strength and stability drives us forward. Starting with You Caring for nearly 3 million people has inspired a transformation. One in which the patient’s experience guides our vision and empowers us to offer new possibilities in our communities. Reshaping Access What is access? It’s offering more sites of care than any other health system in the Midwest. But there’s a new frontier. Access is exploring the latest technologies to deliver care to patients exactly where they are and exactly when they need it Inspiring Professionals With our dynamically inclusive workforce and strong connections to the places where we live and work, we’ll touch more lives and contribute to stronger and more vibrant communities. Transforming Care We’re redefining the standard for care with world-class doctors and caregivers, innovative solutions, outstanding outcomes, and leading-edge research and clinical trials. Combined, Advocate and Aurora are recognized for clinical excellence in: Cardiovascular Care Neurosciences Gynecology Oncology Pediatrics Primary Care Neurology Geriatrics Trauma Care

Requirements

• BSN required
• Registered Nurse license issued by the state in which the teammate practices (add Compact State WI/NC and IL
• Extensive knowledge of Government Audits to lead a clinical RN team to produce expert level appeals for denials associated with LCD/NCD and CMS regulatory components.
• Prior appeal writing for CMS government denials required.
• Extensive background in hospital and professional claim billing as well as DRG/CPT coding knowledge required.
• Strong leader and interpersonal skills required to include education/mentoring for ongoing government audits to develop and enhance team skills to effectively defend denials and ensure financial recovery of reimbursements.

Responsibilities

• Responsible for training, evaluating and staffing coverage for Revenue Recovery.
• Performs quality review process audits and staff feedback.
• Ensures acceptable productivity levels and assigned tasks/appeals are completed
• Identify process inefficiencies and opportunities for daily workflow improvement and participate in developing new processes with Revenue Recovery Manager.
• Keeps abreast of current standards, regulations, and issues related to denials and Revenue Recovery including but not limited to, Government and Insurance Payer reimbursement regulations, clinical practices, utilization management, process improvement and health care industry trends via literature, educational offerings, federal register, etc.
• Maintains an effective working relationship with both internal and external customers.
• Perform clinical denial review and appeals as needed based on coverage needed.
• Ensure personal and staff productivity goals are met or exceeded.
• Monitors and manages daily reports to ensure timely appeals per payer requirements.
• Solid knowledge of CMS and other regulatory requirements.
• Solid understanding of process improvement.
• Demonstrated flexibility, teamwork, and system thinking.
• Proven understanding and analyzing claims and medical records.

Benefits

• Advocate Health offers a comprehensive suite of Total Rewards: benefits and well-being programs, competitive compensation, generous retirement offerings, programs that invest in your career development and so much more – so you can live fully at and away from work, including:
• Compensation Base compensation listed within the listed pay range based on factors such as qualifications, skills, relevant experience, and/or training Premium pay such as shift, on call, and more based on a teammate's job Incentive pay for select positions Opportunity for annual increases based on performance
• Benefits and more Paid Time Off programs Health and welfare benefits such as medical, dental, vision, life, and Short- and Long-Term Disability Flexible Spending Accounts for eligible health care and dependent care expenses Family benefits such as adoption assistance and paid parental leave Defined contribution retirement plans with employer match and other financial wellness programs Educational Assistance Program

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Number of Employees: 11-50 employees